Chapter 50: Assessment and Management of Patients With Biliary Disorders

A client admitted with severe epigastric abdominal pain radiating to the back is vomiting and reports difficulty breathing. Upon assessment, the nurse determines that the client is experiencing tachycardia and hypotension. Which actions are priority interventions for this client? Select all that apply. Administer pain-relieving medication Assist the client to a semi-Fowler position Administer plasma Administer a low-fat diet Administer electrolytes

Administer pain-relieving medication Administer electrolytes Administer plasma Assist the client to a semi-Fowler position The nurse promptly reports decreased blood pressure (BP) and reduced urine output, which indicate hypovolemia and shock or renal failure. The treatment goals for acute pancreatitis focus on relieving pain, maintaining circulatory and fluid volume, and decreasing the production of pancreatic enzymes. Intravenous replacement of fluid and electrolytes should begin immediately because of the loss of fluid in the body. If hypotension is evident, plasma should be administered to maintain BP within an acceptable range. Fluids are administered intravenously and may be accompanied by infusion of blood or blood products to maintain blood volume and to prevent or treat hypovolemic shock. Low serum calcium and magnesium concentrations may occur and require prompt treatment. The nurse maintains the client in a semi-Fowler position to decrease pressure on the diaphragm by a distended abdomen and to increase respiratory expansion. A low-fat diet, with small frequent meals, should be initiated after control of symptoms; it is not an immediate priority.

The nurse should assess for an important early indicator of acute pancreatitis. What prolonged and elevated level would the nurse determine is an early indicator? Serum amylase Serum calcium Serum bilirubin Serum lipase

Serum lipase Serum amylase and lipase levels are used in making the diagnosis of acute pancreatitis, although their elevation can be attributed to many other causes (Feldman et al., 2010). In most cases, serum amylase and lipase levels are elevated within 24 hours of the onset of the symptoms. Serum amylase usually returns to normal within 48 to 72 hours, but serum lipase levels may remain elevated for a longer period, often days longer than amylase.

A nurse is providing dietary instructions to a client with a history of pancreatitis. Which instruction is correct? "Maintain a high-fat diet and drink at least 3 L of fluid a day." "Maintain a high-sodium, high-calorie diet." "Maintain a high-fat, high-carbohydrate diet." "Maintain a high-carbohydrate, low-fat diet."

"Maintain a high-carbohydrate, low-fat diet." A client with a history of pancreatitis should avoid foods and beverages that stimulate the pancreas, such as fatty foods, caffeine, and gas-forming foods; should avoid eating large meals; and should eat plenty of carbohydrates, which are easily metabolized. Therefore, the only correct instruction is to maintain a high-carbohydrate, low-fat diet. An increased sodium or fluid intake isn't necessary because chronic pancreatitis isn't associated with hyponatremia or fluid loss.

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority? Anxiety related to unknown outcome of hospitalization Deficient knowledge related to prevention of disease recurrence Imbalanced nutrition: Less than body requirements related to biliary inflammation Acute pain related to biliary spasms

Acute pain related to biliary spasms The chief symptom of cholecystitis is abdominal pain or biliary colic. Typically, the pain is so severe that the client is restless and changes positions frequently to find relief. Therefore, the nursing diagnosis of Acute pain related to biliary spasms takes highest priority. Until the acute pain is relieved, the client can't learn about prevention, may continue to experience anxiety, and can't address nutritional concerns.

When caring for the patient with acute pancreatitis, the nurse must consider pain relief measures. What nursing interventions could the nurse provide? (Select all that apply.) Encouraging bed rest to decrease the metabolic rate Withholding oral feedings to limit the release of secretin Administering parenteral opioid analgesics as ordered Assisting the patient into the prone position Administering prophylactic antibiotics

Encouraging bed rest to decrease the metabolic rate Withholding oral feedings to limit the release of secretin Administering parenteral opioid analgesics as ordered The current recommendation for pain management is the use of opioids, with assessment for their effectiveness and altering therapy if pain is not controlled or increased (Marx, 2009). Nonpharmacologic interventions such as proper positioning (not prone), music, distraction, and imagery may be effective in reducing pain when used along with medications. In addition, oral feedings are withheld to decrease the secretion of secretin.

A client diagnosed with acute pancreatitis is being transferred to another facility. The nurse caring for the client completes the transfer summary, which includes information about the client's drinking history and other assessment findings. Which assessment findings confirm the diagnosis of acute pancreatitis? Adventitious breath sounds and hypertension Presence of easy bruising and bradycardia Presence of blood in the client's stool and recent hypertension Pain with abdominal distention and hypotension

Pain with abdominal distention and hypotension Assessment findings associated with pancreatitis include pain with abdominal distention and hypotension. Blood in stools and recent hypertension aren't associated with pancreatitis; fatty diarrhea and hypotension are usually present. Presence of easy bruising and bradycardia aren't found with pancreatitis; the client typically experiences tachycardia, not bradycardia. Adventitious breath sounds and hypertension aren't associated with pancreatitis.

Because clients with pancreatitis cannot tolerate high-glucose concentrations, total parental nutrition (TPN) should be used cautiously with them. Which of the following interventions has shown great promise in the prognosis of clients with severe acute pancreatitis? Maintaining a high-Fowler's position Administering oral analgesics around the clock Providing intensive insulin therapy Allowing a clear liquid diet during the acute phase

Providing intensive insulin therapy Intensive insulin therapy (continuous infusion) in the critically ill client has undergone much study and has shown promise in terms of positive client outcomes when compared with intermittent insulin dosing. Glycemic control with normal or near normal blood glucose levels improves client outcomes. Total parental nutrition (TPN) is used carefully in clients with pancreatitis because some clients cannot tolerate a high-glucose concentration, even with insulin coverage. Clients with pancreatitis should not be given high-fat foods because they are difficult to digest. The current recommendation for pain management in this population is parenteral opioids. The nurse should maintain the client in a semi-Fowler's position to reduce pressure on the diaphragm.

A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note: light amber urine. circumoral pallor. yellow sclerae. black, tarry stools.

yellow sclerae. Yellow sclerae are an early sign of jaundice, which occurs when the common bile duct is obstructed. Urine normally is light amber. Circumoral pallor and black, tarry stools don't occur in common bile duct obstruction; they are signs of hypoxia and GI bleeding, respectively.

A nurse manager prepares teaching for staff nurses who care for clients with diabetes. Which statements will the nurse manager include when discussing the differences between the endocrine and exocrine functions of the pancreas? Select all that apply. "Internal secretion of hormones is the function of the endocrine pancreas." "The endocrine pancreas secretes hormones through a ductless gland." "The exocrine pancreas secretes hormones from excretory ducts." "Internal secretion of hormones is the function of the exocrine pancreas." "The exocrine pancreas secretes pancreatic enzymes into the GI tract."

"Internal secretion of hormones is the function of the endocrine pancreas." "The endocrine pancreas secretes hormones through a ductless gland." "The exocrine pancreas secretes hormones from excretory ducts." "The exocrine pancreas secretes pancreatic enzymes into the GI tract." The pancreas has both endocrine and exocrine functions. The endocrine pancreas secretes hormones internally through a ductless gland. The exocrine pancreas secretes external hormones from excretory ducts. Also, the exocrine pancreas secretes pancreatic enzymes into the GI tract.

A client has a nasogastric (NG) tube for suction and is NPO after a pancreaticoduodenectomy. Which explanation made by the nurse is the major purpose of this treatment? "The tube helps control fluid and electrolyte imbalance." "The tube allows toxins to be removed." "The tube provides relief from nausea and vomiting." "The tube allows the gastrointestinal tract to rest."

"The tube allows the gastrointestinal tract to rest." Postoperative management of clients who have undergone a pancreatectomy or a pancreaticoduodenectomy is similar to the management of clients after extensive gastrointestinal or biliary surgery. An NG tube with suction and parenteral nutrition allow the gastrointestinal tract to rest while promoting adequate nutrition.

Ursodeoxycholic acid (UDCA) has been used to dissolve small, radiolucent gallstones. Which duration of therapy is required to dissolve the stones? 1 to 4 months 4 to 6 months 6 to 12 months Over 1 year

6 to 12 months Six to 12 months of therapy with UDCA is recommended in clients to dissolve the stones.

A client with a history of alcohol abuse comes to the emergency department and complains of abdominal pain. Laboratory studies help confirm a diagnosis of acute pancreatitis. The client's vital signs are stable, but the client's pain is worsening and radiating to his back. Which intervention takes priority for this client? Providing mouth care Maintaining nothing-by-mouth (NPO) status Placing the client in a semi-Fowler's position Administering morphine I.V. as ordered

Administering morphine I.V. as ordered The nurse should address the client's pain issues first by administering morphine I.V. as ordered. Placing the client in a Semi-Fowler's position, maintaining NPO status, and providing mouth care don't take priority over addressing the client's pain issues.

A client with calculi in the gallbladder is said to have Cholelithiasis Choledocholithiasis Cholecystitis Choledochotomy

Cholelithiasis Calculi, or gallstones, usually form in the gallbladder from the solid constituents of bile; they vary greatly in size, shape, and composition. Cholecystitis is acute inflammation of the gallbladder. Choledocholithiasis is a gallstone in the common bile duct. Choledochotomy is an incision into the common bile duct.

Which enzyme aids in the digestion of fats? Lipase Secretin Amylase Trypsin

Lipase Lipase is a pancreatic enzyme that aids in the digestion of fats. Amylase aids in the digestion of carbohydrates. Secretin is responsible for stimulating secretion of pancreatic juice. Trypsin aids in the digestion of protein.

A 70-year-old client is admitted with acute pancreatitis. The nurse understands that the mortality rate associated with acute pancreatitis increases with advanced age and attributes this to which gerontologic consideration associated with the pancreas? Increases in the rate of pancreatic secretion Development of local complications Decreases in the physiologic function of major organs Increases in the bicarbonate output by the kidneys

Decreases in the physiologic function of major organs Acute pancreatitis affects people of all ages, but the mortality rate associated with acute pancreatitis increases with advancing age. The pattern of complications changes with age. Younger clients tend to develop local complications; the incidence of multiple organ failure increases with age, possibly as a result of progressive decreases in physiologic function of major organs with increasing age.

A patient is diagnosed with mild acute pancreatitis. What does the nurse understand is characteristic of this disorder? Edema and inflammation Sepsis Disseminated intravascular coagulopathy Pleural effusion

Edema and inflammation Mild acute pancreatitis is characterized by edema and inflammation confined to the pancreas. Minimal organ dysfunction is present, and return to normal function usually occurs within 6 months.

When the nurse is caring for a patient with acute pancreatitis, what intervention can be provided in order to prevent atelectasis and prevent pooling of respiratory secretions? Placing the patient in the prone position Perform chest physiotherapy Suction the patient every 4 hours Frequent changes of positions

Frequent changes of positions Frequent changes of position are necessary to prevent atelectasis and pooling of respiratory secretions.

A client with suspected biliary obstruction due to gallstones reports changes to the color of his stools. Which stool color does the nurse recognize as common to biliary obstruction? Green Red Black Gray

Gray A gray-white stool color is common with a biliary obstruction because the stool is no longer colored with bile pigments.

A nurse cares for a client with a disorder of the endocrine function of the pancreas. Which hormones or enzymes may be impacted by this disorder? Select all that apply. Glucagon Somatostatin Amylase Insulin Lipase

Insulin Glucagon Somatostatin Insulin, glucagon, and somatostatin are hormones released by the endocrine function of the pancreas. An impairment impacting endocrine function will impact all of these hormones. Lipase and amylase are enzymes released by the exocrine function of the pancreas and are not directly impacted by endocrine function.

Which condition is the major cause of morbidity and mortality in clients with acute pancreatitis? Shock Pancreatic necrosis MODS Tetany

Pancreatic necrosis Pancreatic necrosis is a major cause of morbidity and mortality in clients with acute pancreatitis. Shock and multiple organ failure may occur with acute pancreatitis. Tetany is not a major cause of morbidity and mortality in clients with acute pancreatitis.

The nurse is caring for a client with acute pancreatitis who is admitted to the intensive care unit to monitor for pulmonary complications. What is the nurse's understanding of the pathophysiology of pulmonary complications related to pancreatitis? Pancreatitis causes alterations to hemoglobin, impairing oxygenation. Pancreatitis can atrophy the diaphragm and alter the breathing pattern. Pancreatitis causes thickening of pulmonary secretions, impairing oxygenation. Pancreatitis can elevate the diaphragm and alter the breathing pattern.

Pancreatitis can elevate the diaphragm and alter the breathing pattern. Aggressive pulmonary care is required for clients with acute pancreatitis. Pancreatitis can elevate the diaphragm and alter the breathing pattern of clients. Pancreatitis can cause retention of pulmonary secretions but does not thicken the secretions. Acute pancreatitis does not alter the hemoglobin.

A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. The physician diagnoses acute pancreatitis. What is the primary goal of nursing care for this client? Teaching about the disease and its treatment Preventing fluid volume overload Maintaining adequate nutritional status Relieving abdominal pain

Relieving abdominal pain The predominant clinical feature of acute pancreatitis is abdominal pain, which usually reaches peak intensity several hours after onset of the illness. Therefore, relieving abdominal pain is the nurse's primary goal. Because acute pancreatitis causes nausea and vomiting, the nurse should try to prevent fluid volume deficit, not overload. The nurse can't help the client achieve adequate nutrition or understand the disease and its treatment until the client is comfortable and no longer in pain.

A client comes to the ED with severe abdominal pain, nausea, and vomiting. The physician plans to rule out acute pancreatitis. The nurse would expect the diagnosis to be confirmed by an elevated result on which laboratory test? Serum bilirubin Serum amylase Serum calcium Serum potassium

Serum amylase Serum amylase and lipase concentrations are used to make the diagnosis of acute pancreatitis. Serum amylase and lipase concentrations are elevated within 24 hours of the onset of symptoms. Serum amylase usually returns to normal within 48 to 72 hours, but the serum lipase concentration may remain elevated for a longer period, often days longer than amylase. Urinary amylase concentrations also become elevated and remain elevated longer than serum amylase concentrations.

A patient with acute pancreatitis puts the call bell on to tell the nurse about an increase in pain. The nurse observes the patient guarding; the abdomen is board-like and no bowel sounds are detected. What is the major concern for this patient? The patient is developing a paralytic ileus. The patient requires more pain medication. The patient has developed peritonitis. The patient has developed renal failure.

The patient has developed peritonitis. Abdominal guarding is present. A rigid or board-like abdomen may develop and is generally an ominous sign, usually indicating peritonitis (Privette et al., 2011).

The nurse is caring for a patient with acute pancreatitis. The patient has an order for an anticholinergic medication. The nurse explains that the patient will be receiving that medication for what reason? To reduce gastric and pancreatic secretions To depress the central nervous system and increase the pain threshold To decrease metabolism To relieve nausea and vomiting

To reduce gastric and pancreatic secretions Anticholinergic medications reduce gastric and pancreatic secretion.

A client with chronic pancreatitis is treated for uncontrolled pain. Which complication does the nurse recognize is most common in the client with chronic pancreatitis? Fatigue Hypertension Diarrhea Weight loss

Weight loss Weight loss is most common in the client with chronic pancreatitis due to decreased dietary intake secondary to anorexia or fear that eating will precipitate another attack. The other answer choices are not the most common complications related to chronic pancreatitis.

A nurse should monitor blood glucose levels for a patient diagnosed with hyperinsulinism. What blood value does the nurse recognize as inadequate to sustain normal brain function? 70 mg/dL 90 mg/dL 30 mg/dL 50 mg/dL

30 mg/dL Hyperinsulinism is caused by overproduction of insulin by the pancreatic islets. Occasionally, tumors of nonpancreatic origin produce an insulin-like material that can cause severe hypoglycemia and may be responsible for seizures coinciding with blood glucose levels that are too low to sustain normal brain function (i.e., lower than 30 mg/dL [1.6 mmol/L]) (Goldman & Schafer, 2012; McPherson & Pincus, 2011).

The nurse knows that the serum amylase concentration returns to normal within which time frame? 12 hours 24 hours 36 hours 48 hours

48 hours Serum amylase usually returns to normal within 48 to 72 hours.

Pharmacologic therapy frequently is used to dissolve small gallstones. It takes about how many months of medication with UDCA or CDCA for stones to dissolve? 13 to 18 3 to 5 1 to 2 6 to 12

6 to 12 Ursodeoxycholic acid (UDCA [URSO, Actigall]) and chenodeoxycholic acid (chenodiol or CDCA [Chenix]) have been used to dissolve small, radiolucent gallstones composed primarily of cholesterol. Six to 12 months of therapy are required in many clients to dissolve stones, and monitoring of the client for recurrence of symptoms or occurrence of side effects (e.g., GI symptoms, pruritus, headache) is required during this time.

The nurse is caring for a client with a biliary disorder who has an elevated amylase level. If this elevation correlates to dysfunction, which body process does the nurse recognize may be impaired? Fat digestion Protein digestion Carbohydrate digestion Protein synthesis

Carbohydrate digestion Amylase is a pancreatic enzyme involved in the breakdown and digestion of carbohydrates. Trypsin aids in the digestion of proteins. Lipase aids in the digestion of fats.

Which foods should be avoided following acute gallbladder inflammation? Mashed potatoes Cheese Cooked fruits Coffee

Cheese The client should avoid eggs, cream, pork, fried foods, cheese, rich dressings, gas-forming vegetables, and alcohol. It is important to remind the client that fatty foods may induce an episode of cholecystitis. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, non-gas-forming vegetables, bread, coffee, or tea may be consumed as tolerated.

A client is admitted to the healthcare facility suspected of having acute pancreatitis and undergoes laboratory testing. Which of the following would the nurse expect to find? Increased serum calcium levels Decreased liver enzyme levels Decreased white blood cell count Elevated urine amylase levels

Elevated urine amylase levels Elevated serum and urine amylase, lipase, and liver enzyme levels accompany significant pancreatitis. If the common bile duct is obstructed, the bilirubin level is above normal. Blood glucose levels and white blood cell counts can be elevated. Serum electrolyte levels (calcium, potassium, and magnesium) are low.

Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray? Hot roast beef sandwich with gravy Mashed potatoes Vanilla pudding White rice

Hot roast beef sandwich with gravy The diet immediately after an episode of acute cholecystitis is initially limited to low-fat liquids. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, bread, and coffee or tea may be added as tolerated. The client should avoid fried foods such as fried chicken, because fatty foods may bring on an episode of cholecystitis.

A client with acute pancreatitis has been started on total parenteral nutrition (TPN). Which action should the nurse perform after administration of the TPN? Auscultate the abdomen for bowel sounds every 4 hours Measure blood glucose concentration every 4 to 6 hours Measure abdominal girth every shift Monitor for reports of nausea and vomiting

Measure blood glucose concentration every 4 to 6 hours Enteral or parenteral nutrition may be prescribed. In addition to administering enteral or parenteral nutrition, the nurse monitors the serum glucose concentration every 4 to 6 hours.

The nurse identifies a potential collaborative problem of electrolyte imbalance for a client with severe acute pancreatitis. Which assessment finding alerts the nurse to an electrolyte imbalance associated with acute pancreatitis? Hypotension Elevated blood glucose concentration Paralytic ileus and abdominal distention Muscle twitching and finger numbness

Muscle twitching and finger numbness Muscle twitching and finger numbness indicate hypocalcemia, a potential complication of acute pancreatitis. Calcium may be prescribed to prevent or treat tetany, which may result from calcium losses into retroperitoneal (peripancreatic) exudate. The other data indicate other complications of acute pancreatitis but are not indicators of electrolyte imbalance.

One difference between cholesterol stones (left) and the stones on the right are that the ones on the right account for only 10% to 25% of cases of stones in the United States. What is the name of the stones on the right? Pixelated Pearl Pigment Patterned

Pigment There are two major types of gallstones: those composed predominantly of pigment and those composed primarily of cholesterol. Pigment stones probably form when unconjugated pigments in the bile precipitate to form stones; these stones account for 10% to 25% of cases in the United States. There are no gallstones with the names of pearl, patterned, or pixelated.

A client comes to the ED with severe abdominal pain, nausea, and vomiting. The physician plans to rule out acute pancreatitis. The nurse would expect the diagnosis to be confirmed by an elevated result on which laboratory test? Serum potassium Serum bilirubin Serum amylase Serum calcium

Serum amylase Serum amylase and lipase concentrations are used to make the diagnosis of acute pancreatitis. Serum amylase and lipase concentrations are elevated within 24 hours of the onset of symptoms. Serum amylase usually returns to normal within 48 to 72 hours, but the serum lipase concentration may remain elevated for a longer period, often days longer than amylase. Urinary amylase concentrations also become elevated and remain elevated longer than serum amylase concentrations.

A client with acute pancreatitis reports muscle cramping in the lower extremities. What pathophysiology concept represents the reason the client is reporting this? Tetany related to hypocalcemia Muscle pain related to referred pain manifestations Muscle spasm related to hypokalemia Tetany related to hypercalcemia

Tetany related to hypocalcemia A client with acute pancreatitis who reports muscle cramping or pain should be suspected of having hypocalcemia and tetany of the muscles. Hypocalcemia may occur in acute pancreatitis because, when auto digestion of the pancreas occurs, calcium binds to fatty acids and calcium is decreased in the blood. This is a potentially life-threatening complication of pancreatitis and needs to be immediately addressed.

The nurse is planning care for a client following an incisional cholecystectomy for cholelithiasis. Which intervention is the highest nursing priority for this client? Teaching the client to choose low-fat foods from the menu Performing range-of-motion (ROM) leg exercises hourly while the client is awake Assisting the client to ambulate the evening of the operative day Assisting the client to turn, cough, and deep breathe every 2 hours

Assisting the client to turn, cough, and deep breathe every 2 hours Assessment should focus on the client's respiratory status. If a traditional surgical approach is planned, the high abdominal incision required during surgery may interfere with full respiratory excursion. The other nursing actions are also important, but are not as high a priority as ensuring adequate ventilation.

Which intervention should be included in the plan of care for a client who has undergone a cholecystectomy? Assessing the color of the sclera every shift Placing the client in the semi-Fowler position immediately after surgery Placing the client on NPO (nothing by mouth) status for 2 days after surgery Clamping the T-tube immediately after surgery

Assessing the color of the sclera every shift If bile is not draining properly, an obstruction is probably causing bile to be forced back into the liver and bloodstream. Because jaundice may result, the nurse should assess the color of the sclerae.

Which of the following would be most appropriate for a client who is experiencing biliary colic? Avoid administering analgesics. Ensure that the client has eaten a full meal. Avoid administering antispasmodics. Ensure that the client rests.

Ensure that the client rests. During an attack of biliary colic, the nurse should ensure that the client rests. The nurse should not give the client a full meal; instead, the nurse should monitor the client's ability to digest a bland liquid diet. The nurse should also administer antispasmodics or analgesics as prescribed to relieve pain and discomfort.

Which condition in a client with pancreatitis makes it necessary for the nurse to check fluid intake and output, check hourly urine output, and monitor electrolyte levels? Dry mouth, which makes the client thirsty Frequent vomiting, leading to loss of fluid volume Acetone in the urine High glucose concentration in the blood

Frequent vomiting, leading to loss of fluid volume Fluid and electrolyte disturbances are common complications because of nausea, vomiting, movement of fluid from the vascular compartment to the peritoneal cavity, diaphoresis, fever, and the use of gastric suction. The nurse assesses the client's fluid and electrolyte status by noting skin turgor and moistness of mucous membranes. The nurse weighs the client daily and carefully measures fluid intake and output, including urine output, nasogastric secretions, and diarrhea.

A client is scheduled for a cholecystogram for later in the day. What is the nurse's understanding on the diagnostic use of this exam? It shows the sizes of the abdominal organs and detects any masses. It visualizes the biliary structures and pancreas via endoscopy. It visualizes the liver and pancreas. It visualizes the gallbladder and bile duct.

It visualizes the gallbladder and bile duct. The cholecystogram is a diagnostic imaging test used to visualize the gallbladder and bile duct. The celiac axis arteriography visualizes the liver and pancreas. Ultrasonography shows the sizes of the abdominal organs and detects any masses. The endoscopic retrograde cholangiopancreatography (ERCP) visualizes the biliary structures and pancreas via endoscopy.

Which of the following conditions is most likely to involve a nursing diagnosis of fluid volume deficit? Appendicitis Pancreatitis Cholecystitis Peptic ulcer

Pancreatitis Hypotension is typical and reflects hypovolemia and shock caused by the loss of large amounts of protein-rich fluid into the tissues and peritoneal cavity. The other conditions are less likely to exhibit fluid volume deficit.

Which condition is most likely to have a nursing diagnosis of fluid volume deficit? Appendicitis Gastric ulcer Pancreatitis Cholecystitis

Pancreatitis Hypovolemic shock from fluid shifts is a major factor in acute pancreatitis. Appendicitis, cholecystitis, and gastric ulcer are less likely to exhibit fluid volume deficit.

The nurse cares for a client with cholecystitis with severe biliary colic symptoms. Which nursing intervention best promotes adequate respirations in a client with these symptoms? Encourage the client to ambulate frequently. Place the client in semi-Fowler's position. Instruct the client on the proper use of an incentive spirometer. Encourage the client to deep breathe and cough.

Place the client in semi-Fowler's position. A client with severe biliary colic is in extreme pain and has a very difficult time taking a deep breath due to severe pain on inspiration. Placing the client in upright or semi-Fowler's position best promotes adequate breathing and best supports the client's function. Ambulation, deep breathing and coughing, and incentive spirometry may be too difficult or impossible for the client with severe biliary colic symptoms.

A client being treated for pancreatitis faces the risk of atelectasis. Which of the following interventions would be important to implement to minimize this risk? Instruct the client to avoid coughing. Withhold oral feedings for the client. Monitor pulse oximetry every hour. Reposition the client every 2 hours.

Reposition the client every 2 hours. Repositioning the client every 2 hours minimizes the risk of atelectasis in a client who is being treated for pancreatitis. The client should be instructed to cough every 2 hours to reduce atelectasis. Monitoring the pulse oximetry helps show changes in respiratory status and promote early intervention, but it would do little to minimize the risk of atelectasis. Withholding oral feedings limits the reflux of bile and duodenal contents into the pancreatic duct.

The nurse should assess for an important early indicator of acute pancreatitis, which is a prolonged and elevated level of: Serum amylase Serum bilirubin Serum calcium Serum lipase

Serum lipase Serum amylase and lipase levels are elevated within 24 hours of the onset of symptoms. Serum amylase usually returns to normal within 48 to 72 hours, but serum lipase levels may remain elevated days longer than amylase.

The physician has written the following orders for a new client admitted with pancreatitis: bed rest, nothing by mouth (NPO), and administration of total parenteral nutrition (TPN) . Which does the nurse attribute as the reason for NPO status? To avoid inflammation of the pancreas To drain the pancreatic bed To prevent the occurrence of fibrosis To aid opening up of pancreatic duct

To avoid inflammation of the pancreas Pancreatic secretion is increased by food and fluid intake and may cause inflammation of the pancreas.

A client with carcinoma of the head of the pancreas is scheduled for surgery. Which of the following should a nurse administer to the client before surgery? Oral bile acids Potassium Vitamin K Vitamin B

Vitamin K Clients with carcinoma of the head of the pancreas typically require vitamin K before surgery to correct a prothrombin deficiency. Potassium would be given only if the client's serum potassium levels were low. Oral bile acids are not prescribed for a client with carcinoma of the head of the pancreas; they are given to dissolve gallstones. Vitamin B has no implications in the surgery.

The digestion of carbohydrates is aided by amylase. secretin. lipase. trypsin.

amylase. Amylase is secreted by the exocrine pancreas. Lipase aids in the digestion of fats. Trypsin aids in the digestion of proteins. Secretin is the major stimulus for increased bicarbonate secretion from the pancreas.

A critical care nurse is caring for a client with acute pancreatitis. One potentially severe complication involves the respiratory system. Which of the following would be an appropriate intervention to prevent complications associated with the respiratory system? Withhold oral feedings. Maintain the client in a semi-Fowler's position. Administer enteral or parenteral nutrition. Carry out wound care as prescribed.

Maintain the client in a semi-Fowler's position. The nurse maintains the client in the semi-Fowler's position to decrease pressure on the diaphragm by a distended abdomen and to increase respiratory expansion. Respiratory distress and hypoxia are common, and the client may develop diffuse pulmonary infiltrates, dyspnea, tachypnea, and abnormal blood gas values. The client who has undergone surgery may have multiple drains or an open surgical incision and is at risk for skin breakdown and infection. Oral food or fluid intake is not permitted; therefore, enteral or parenteral feedings may be prescribed.

When caring for a client with acute pancreatitis, the nurse should use which comfort measure? Positioning the client on the side with the knees flexed Administering an analgesic once per shift, as ordered, to prevent drug addiction Administering frequent oral feedings Encouraging frequent visits from family and friends

Positioning the client on the side with the knees flexed The nurse should place the client with acute pancreatitis in a side-lying position with knees flexed; this position promotes comfort by decreasing pressure on the abdominal muscles. The nurse should administer an analgesic, as needed and ordered, before pain becomes severe, rather than once each shift. Because the client needs a quiet, restful environment during the acute disease stage, the nurse should discourage frequent visits from family and friends. Frequent oral feedings are contraindicated during the acute stage to allow the pancreas to rest.

A nurse is teaching a client about the cause of acute pancreatitis. The nurse evaluates the teaching as effective when the client correctly identifies which condition as a cause of acute pancreatitis? Use of loop diuretics to increase the incidence of pancreatitis Fibrosis and atrophy of the pancreatic gland Self-digestion of the pancreas by its own proteolytic enzymes Calcification of the pancreatic duct, leading to its blockage

Self-digestion of the pancreas by its own proteolytic enzymes Self-digestion of the pancreas by its own proteolytic enzymes, principally trypsin, causes acute pancreatitis. Of clients with acute pancreatitis, 80% had undiagnosed chronic pancreatitis. Gallstones enter the common bile duct and lodge at the ampulla of Vater, obstructing the flow of pancreatic juice or causing a reflux of bile from the common bile duct into the pancreatic duct, thus activating the powerful enzymes within the pancreas. Normally, these remain in an inactive form until the pancreatic secretions reach the lumen of the duodenum. Activation of the enzymes can lead to vasodilation, increased vascular permeability, necrosis, erosion, and hemorrhage.

The nurse should assess for an important early indicator of acute pancreatitis. What prolonged and elevated level would the nurse determine is an early indicator? Serum calcium Serum bilirubin Serum amylase Serum lipase

Serum lipase Serum amylase and lipase levels are used in making the diagnosis of acute pancreatitis, although their elevation can be attributed to many other causes (Feldman et al., 2010). In most cases, serum amylase and lipase levels are elevated within 24 hours of the onset of the symptoms. Serum amylase usually returns to normal within 48 to 72 hours, but serum lipase levels may remain elevated for a longer period, often days longer than amylase.

Which is a clinical manifestation of cholelithiasis? Epigastric distress before a meal Clay-colored stools Nonpalpable abdominal mass Abdominal pain in the upper left quadrant

Clay-colored stools The client with gallstones has clay-colored stools and excruciating upper right quadrant pain that radiates to the back or right shoulder. The excretion of bile pigments by the kidneys makes urine very dark. The feces, no longer colored with bile pigments, are grayish (like putty) or clay colored. The client develops a fever and may have a palpable abdominal mass.